- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.64 / $2,217.64 / $2,885.79
| Facility | | $2,217.64 | $2,217.64 | $2,885.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.13 / $2,373.05 / $2,885.79
| Professional | | $2,074.13 | $2,373.05 | $2,885.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,613.67 / $2,639.01 / $3,436.18
| Facility | | $1,613.67 | $2,639.01 | $3,436.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.13 / $2,373.05 / $2,885.79
| Professional | | $2,074.13 | $2,373.05 | $2,885.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.28 / $1,324.07 / $2,206.78
| Professional | | $1,095.28 | $1,324.07 | $2,206.78 |